In this assignment, you will continue to develop the Methods section of your proposed proposal. The focus of the current assignment is continued to refine previously submitted sections of the proposal

34

Implementation of Type 2 Diabetes Self-Management Education in an Impoverished Community

Name

NGR 7911

Dr.

University

Date

Background and Significance: Impoverished and rural communities are at a higher risk of Type 2 diabetes (T2D)-a condition which can be managed using self-management intervention methods such as physical exercise, eating cleaner and lean diets, and monitoring blood sugar levels. T2D patients from impoverished communities bear a considerable burden because they find it challenging to apply self-management practices due to barriers like lack of proper patient education, support from friends and families, and shortage of resources.

Project Goals and Objectives: The project aims to promote and implement effective self-management for T2D in impoverished communities. While self-management could be a better alternative for managing T2D in rural communities, its effectiveness might be affected if misused. Hence, the project will also assess barriers to self-management among people with diabetes in impoverished communities and strategize practical ways of promoting this practice while keeping risks at a minimum.

Methods: Semi-structured interviews will be administered to patients to help collect information on how effective self-management has been in managing T2D and the challenges that they face in managing the disease. Patients will then be offered patient education and monitored during the project. The effects of the intervention will be measured by assessing a patient’s HbA1c and glycemic levels before and after the project to determine project success.

Potential Impact of the Project: The successful implementation of self-management will help ease the burden that T2D patients face while trying to access pharmacological treatment and management of the disease. It will improve the health outcomes of diabetics in rural communities by increasing patient education on safe and effective self-management practices managing the disease. The project will also promote peer support by educating the families and friends of these patients on the same.

Abstract 2

Table of Contents 4

Introduction 6

Background, Significance 6

Description of Organization 8

Mission 9

Organizational Structure 9

Organizational Needs Assessment 9

Organizational Data Indicating a Problem 9

Stakeholder Analysis 11

Project Management Tools 14

Local Problem Statement 15

Literature Review 16

Description of Search Strategy 16

Search Strategy 16

Synthesized Key Findings 18

Interventions Used to Improve the Problem and their Outcomes 18

Facilitators and Barriers to Implementation of the Interventions Identified 21

Purpose and Project Goals 22

EBP Model 23

Methods 23

Description of Intervention 23

Outcome Measures 25

Description of Each Measure and Rationale for Selecting the Measure 25

Validity and Reliability 26

Data Collection Methods 27

Semi-structured interviews 27

Questionnaires 27

Surveys 27

Data Analysis Plan 28

Appendices 35

Appendix A - Summary of Evidence Table 35

Appendix B - Project Management Tools 49

Appendix C - SWOT Analysis 50

Appendix E-DSM Pre and Post-Survey Questions 52

Appendix F-Five-Item Questionnaire 54

Abstract 2

Table of Contents 4

Introduction 6

Background, Significance 6

Description of Organization 8

Mission 9

Organizational Structure 9

Organizational Needs Assessment 9

Organizational Data Indicating a Problem 9

Stakeholder Analysis 11

Patients 11

Professional Organizations 12

Interdisciplinary Colleagues 12

Project Management Tools 14

SWOT Analysis 14

Local Problem Statement 15

Literature Review 16

Description of Search Strategy 16

Search Strategy 16

Synthesized Key Findings 18

Interventions Used to Improve the Problem and their Outcomes 18

Peer Support or Coaching or Peer Health Coaching 18

Patient Education 19

Lifestyle Modification Programs 19

Problem-solving or Problem-Solving Therapy 20

Facilitators and Barriers to Implementation of the Interventions Identified 21

Purpose and Project Goals 22

EBP Model 23

Methods 23

Description of Intervention 23

Outcome Measures 25

Description of Each Measure and Rationale for Selecting the Measure 25

Validity and Reliability 26

Data Collection Methods 27

Semi-structured interviews 27

Questionnaires 27

Surveys 27

Data Analysis Plan 28

Appendices 35

Appendix A - Summary of Evidence Table 35

Appendix B - Project Management Tools 49

Appendix C - SWOT Analysis 50

Appendix E-DSM Pre and Post-Survey Questions 52

Appendix F-Five-Item Questionnaire 54

Ethnic and racial minority groups in the US, particularly impoverished communities, bear a more significant load from the increasing incidence of Type 2 diabetes (T2D), making the disease a primary focus for disparities in healthcare research (Haw et al., 2021). T2D is a complicated, dire disease in which the weight of self-care is on the patient. In the United States, there are approximately 37.3 million people with diabetes (Centers for Disease Control and Prevention, 2022). Unfortunately, T2D is among the greatest difficult chronic health conditions to manage and control. The increased demand for disease management and the incorporation of complicated self-management routines in the day-to-day lives of diabetics has been proven to lead to increased stress, leaving individuals discouraged, frustrated, and overwhelmed. These demands could also cause depression, anxiety, and reduced well-being (Papelbaum et al., 2010). However, patient behaviors such as lifestyle modifications associated with exercise and diet, medication, record keeping, and daily blood glucose monitoring are crucial in effectively managing the disease (Shrivastava et al., 2013). These behaviors are often referred to as self-management.

Self-management is participating in self-care actions to enhance a person's well-being and behaviors (Shrivastava et al., 2013). This considerable burden affects patients from impoverished communities that usually find it challenging to deal with self-management. This is mainly because of cultural, economic, and social barriers, inadequate access to diabetes self-care and self-management resources, and high survival demands among disadvantaged populations (Haw et al., 2021). Recent immigrants and refugees might also experience difficulties adhering to diabetes self-management practices due to various factors, including the absence of preventive care, leading to late treatment and diagnosis (Heerman & Wills, 2011). Cultural differences in how people perceive the origin and treatment of diabetes might also make it challenging to manage the disease among disadvantaged populations (Heerman & Willis, 2011).

Nonetheless, self-management is the most effective way of managing diabetes among populations that lack access to quality healthcare (Whittemore et. al. 2019). Most of these practices require considerably fewer financial resources than frequent healthcare visits. For instance, self-management practices require patients to control and monitor their diet, engage in more physical activity, and monitor their glucose levels, which is more affordable than other management options (Shrivastava et al., 2013). However, social support systems might address the effects of environmental and economic challenges that affect effective T2D management by increasing access to social capital, thus promoting self-efficacy behaviors. Nam et al. (2011) state that social support is essential since it is related to the hindrance and facilitation of self-care among patients suffering from chronic diseases like diabetes. Families are the key foundation of social support since they help patients manage their condition successfully.

Ideally, social support is multifaceted and correlates with several social networks (institutional, community-based, occupational, or familial) surrounding a patient (Nam et al. 2011). It has a high potential to exert either negative or positive influences on the person's capability to control the condition independently. A patient's capacity to use social capital to capitalize on established resources could play a significant responsibility in self-care. They could activate constructive social capital resources by seeking and getting help from substantial people in several social positions, such as family members that understand how to manage the disease, thus minimizing the challenges associated with their poverty status that limit them from addressing the condition effectively. In most cases, some attributes of the healthcare system affect effective disease self-care, especially among disadvantaged communities for whom the cost and access to healthcare might provide significant barriers to achieving effective self-management (Nam et al. 2011).

It is crucial to address self-management among T2D patients in impoverished communities because these patients are a vulnerable population hence it is important to ensure that they take up safe and effective self-management behaviors to avoid any further deterioration of their health.

The organization is committed to offering care to T2D patients in impoverished societies. It is a non-profit which endeavors to enhance the health status of people in these populations by providing patient education on the management of diseases, provide cost-effective treatment options to people in rural societies because they lack the finances to access quality care, and spread awareness on different diseases. The organization has a multidisciplinary team which helps provide care to impoverished communities. The team comprises nutritionists, therapists such as occupational therapists, normal healthcare practitioners, lifestyle coaches, among other healthcare staff.

"To provide quality and affordable healthcare services to patients in impoverished communities. The organization also provides patient education on effective strategies of managing various diseases to reduce healthcare costs.”

The organization is made up of board members, professional members, a multidisciplinary team, nutritionists, doctors, and nurses. The board members oversee all the functions and activities in the organization and approve the decisions that are made in the institution. The multidisciplinary team helps provide care to patients in the community and analyze the problems affecting these patients to determine how the organization can help solve these problems.

According to the National Diabetes Statistics Report, roughly 8.2% of the United States population (26.9 million individuals) were diagnosed with diabetes in 2018 (Center for Disease Control and Prevention, 2020). In 2016, around 12.6 % of US citizens in non-metropolitan regions were diagnosed with diabetes, a higher statistic than 9.9 % in metropolitan regions (Center for Disease Control and Prevention, 2020). In the 'diabetes belt', the incidence of diabetes was about 11.7 % of the entire US population. Over one-third of counties within the diabetic belt are in the Appalachian Region. Many states within the belt are extremely rural compared to the United States average (Centers for Disease Control and Prevention, 2022). These statistics show that diabetes is a major concern within impoverished and rural communities because of limited access to healthcare services and a higher prevalence of risk factors (Misra et al., 2019). For instance, impoverished communities often comprise populations at a higher risk of T2D, such as ethnic and racial groups and older adults (Mendenhall et al., 2017).

Additionally, several barriers affect patient education and quality healthcare access in impoverished communities. First, fewer transport options in rural areas make it challenging for T2D patients to travel to doctor appointments (Stotz et al., 2021). Secondly, there are higher rates of uninsured patients in rural communities. Limited access to medical covers makes it difficult for impoverished populations to access medical supplies, affordable medications, and cover medical appointments. Also, there are fewer healthcare providers in poor communities, making it difficult to offer patient education, replace retiring healthcare professionals, and retain nutritionists and dietitians. Workforce shortages in impoverished societies also limit access to specialized healthcare professionals, including endocrinologists (North et al., 2022).

These data indicate a major problem within the organization because it is in an impoverished communities since T2D patients would fail to access pharmacological interventions for managing the disease. However, with the introduction of self-management practices, individuals in rural communities could learn about some of the efficient lifestyle modifications they should make to control their weight and glycemic levels. Self-management is cheaper and less cumbersome because it only requires the efforts of a patient and their family to manage the disease.

The main stakeholders relevant to this project include patients, their families, the family advisory committee, professional organizations such as the American Diabetes Association (ADA), and interdisciplinary colleagues such as social workers, nutritionists, physicians, or occupational therapists (OT)/PT.

Patients are the main stakeholders in this project because the project will have a significant impact on them. This project will help patients understand how self-care and self-management could help manage T2D. Their families will also benefit from the project because they will be able to recognize effective strategies to incorporate self-management into their management regimen. Another major thing that patients, family advisory committees, and relatives need to understand from the project is examples of self-management interventions that have been proven effective in managing T2D through consistent follow up with a medical provider. Patients and their families are also a great asset to the project because they will contribute by taking part in the project and having outcomes measured like HbA1c and glycemic levels. Also, families of patients with the disease can contribute to the project by providing crucial information on the efficacy of the self-management interventions they have used on their relatives. However, patients might impede the project by providing false information on self-management efficiency and failing to commit to follow up for self-management interventions. Families can also affect the project by failing to give their relatives with type II diabetes the correct self-management interventions during the project period. The engagement of patients and their families in this project requires that self-care and self-management education be offered.

Utilizing professional organizations such as the American Diabetes Association (ADA) will help inform the project by using already developed evidence-based strategies for diabetes self-management to determine whether the identified strategies are safe and effective in managing T2D. These organizations would contribute to the project because they have materials that will be used to offer the project's respondents patient education. The best way to engage professional organizations is using their materials to offer patient education on safe self-management practices for T2D.

In a healthcare setting, an interdisciplinary team consists of practitioners from different disciplines that work together to address a patient's psychological and physical needs. For instance, for a patient with T2D, the interdisciplinary team comprises respiratory therapists, nutritionists, occupational therapists, and other physicians. These stakeholders are crucial to the project because they will help inform the project and play a role in encouraging continued self-management behaviors. The main thing that this group of stakeholders is concerned with is whether self-management interventions are effective in managing T2D. This project will help them understand the self-management practices they would recommend to patients other than pharmacological interventions. Interdisciplinary colleagues could also contribute significantly to the project. For instance, nutritionists are well-equipped with the correct information on healthy diets for patients suffering from different diseases. Therefore, they will help recommend healthy lifestyles and dietary changes which would help control HbA1c and daily glycemic levels and weight. Additionally, occupational therapists (OT) are healthcare professionals that help injured, disabled, or sick patients improve, recover, or develop by maintaining the life skills needed for healthy living (Burson, Fette, & Kannenberg, 2017). Therefore, they could help T2D patients maintain, recover, and develop meaningful occupations or activities for communities, groups, and individuals.

The interdisciplinary team could affect or obstruct this project when they do not recommend and administer appropriate and efficient self-management interventions for the project participants. For instance, if a nutritionist recommends a diet that would not be effective in reducing glycemic levels in a patient with T2D, then the project findings will be affected when a diabetic’s health status deteriorates with the adoption of self-management. Similarly, suppose an occupational therapist does not help a patient to develop a healthy lifestyle to manage the disease adequately. Patient health outcomes will be affected in that case, impacting the project's findings.

Refer to Appendix B for a driver diagram.

Several factors would impede the efficient implementation of this project in the given practice setting (See Appendix C for the SWOT Analysis diagram of these factors).

Strengths

i. There is access to respondents who would help provide information on which strategies they have adopted and utilized in the effective management of T2D other than pharmaceutical interventions since the given setting is my organization which is in an impoverished community.

ii. There is the availability of experienced researchers and professionals (such as nutritionists and occupational therapists) to help recommend effective self-management interventions to the project’s respondents.

Weaknesses

i. Lack of funding because there are fewer financial resources in impoverished communities; hence project initiators must fund the project themselves or look for a professional organization willing to fund the research.

ii. Limiting beliefs among individuals, such as using cultural interventions like traditional herbs and ayurvedic medications, is the most effective way of preventing and treating T2D (Ahmad, 2021). These beliefs might impede the effective implementation of self-management interventions.

Opportunities

i. Increased interest among professional organizations and leading scientific institutions to research effective disease management strategies. This project also provides an opportunity of increasing awareness of self-management practices in this community.

ii. The availability of professional organizations which help offer materials which will be useful in providing education to patients with T2D in impoverished communities.

Threats

i. Language and cultural barriers. The project lead might find it difficult to communicate with T2D patients from impoverished communities.

T2D patients at my facility in the impoverished communities have limited education on a current standardized process for providing self-management education. Their health status deteriorates further due to a limited access to healthcare services due to different factors, such as geographical and financial barriers; this accounts for the high rates of T2D within these communities since patients lack professionals to guide them through pharmacological interventions. These high statistics could be mitigated through dietary and lifestyle modifications. Because treatments such as insulin and drugs are expensive and impoverished communities have fewer resources, it is important to prioritize prevention and manage the disease using self-management practices. It is also essential to spread awareness and educate patients during the consistent follow up visits on how lifestyle changes could be as effective as using drugs to manage and prevent T2D.

An all-inclusive search was performed through Ebscohost utilizing the following databases: PsycInfo, PsycArtiCLES, MEDLINE, Health Source: Nursing/Academic Edition, CINAHL, and Academic Search Complete. The search was conducted to establish best practices in self-management interventions for T2D. The top search terms used include randomized controlled trials, self-management, patient education, self-care, type 2 diabetes, and diabetes mellitus. Only peer-reviewed articles written in English between January 2015 to 2022 were selected. Additionally, the Cochrane Library was looked up for self-management review. The first search yielded 62 peer-reviewed articles abstracted for self-management intervention topics. This topic was screened independently and then selected articles for quality appraisal and inclusion criteria. Once the pieces were screened, a quality appraisal and inclusion criteria were developed. For the articles to be included in the official review, they were analyzed using the following inclusion criteria. The article must have the following:

i. Provided quantitative and qualitative empirical (descriptive, cohort study, quasi-experimental, RCT, systematic review, or meta-analysis) evaluative support.

ii. Identified an intervention.

iii. Included an outcome variable of self-care and self-management.

iv. Included adult respondents with type II diabetes.

v. Operationalized as a psychosocial indicator (such as support, stage of change, depression, stress, or emotional adjustment), physiological indicator (such as cholesterol, HbA1c, weight, blood pressure, blood glucose level), self-management outcomes (such as SBGM pattern, medication, exercise, diet) and knowledge. Forty-six articles were excluded since they failed to meet the inclusion criteria because they focused on T1D rather than T2D. Duplicates were removed from search results. The themes of the remaining sixteen articles selected for review included patient education, lifestyle modification programs, peer support, and lifestyle adaptation. The reference lists of the selected articles were then analyzed to locate other relevant articles in the search. At the end of the reviews and search, 14 articles were chosen for synthesis. All articles chosen for review were critically appraised using the Johns Hopkins Evidence-Based Practice Model Heirchy of Evidence guide.

The quality of the articles selected for this review could be summarized as high-quality randomized clinical trials (n=1), good-quality systematic reviews (n=2), good-quality meta-analysis (n=1), moderate-quality integrative review (n=1), high-quality qualitative descriptive study (n=11), and good quality literature reviews (n=4). See Appendix A for evidence table.

Peer support, peer coaching, and health coaching utilize volunteers or health care providers, often referred to as peer supporters or coaches, to offer self-management care to individuals with the same healthcare condition as them or those they consider their peers (Thom et al., 2013; Ghorob et al., 2011). These peers and coaches could include healthcare professionals, family members, educators, community health workers, and patients. Ideally, peer health coaching is done to connect a patient to other patients that have the same health issues. Regardless of peer support or coaching, the objective is to motivate and engage T2D patients in self-care and self-management. Peer support and coaching interventions have been adequately researched in disease education. Tang et al. (2011) explains that in diabetes self-management, peers and coaches play multiple roles, such as group facilitator, mentor, case manager, educator, cultural translator, and advocate. Peer support and coaching are often delivered by trained professionals and primarily emphasize self-management interventions based on documented curricula and time limited. Based on efficiency, support and peer health coaching have effectively helped lower HbA1c levels and improve self-management (Powers et al., 2015; Moskowitz et al., 2013). Due to such favorable results, peer support and health coaching have received significant interest as effective interventions for disease self-care (Aschbrenner et al., 2015).

Diabetes self-management education (DSME) has been the most common and effective strategy for managing diabetes (Pamungkas, Chamroonsawasdi, & Vatanasomboon, 2017). This intervention program has evolved over the decades to include biopsychosocial treatment models and affective and behavioral tactics to deal with the psychosocial and medical requirements of individuals with T2D (Carpenter, DiChiacchio, & Barker, 2019). Patient education could be administered in different modalities, to groups or individuals, professionals, or peers, in extended or short-term sessions. DSME entails various crucial components (monitoring checks, physical activity, adherence to diet, and treatments) that should be maintained to prevent complications related to diabetes (Carpenter, DiChiacchio, & Barker, 2019). Powers et al. (2015) found that implementing self-management education effectively improves the quality of life for T2D. For instance, the ADA have a toolkit for implementing DSME into different practices.

Lifestyle modification programs are used to improve health outcomes through behavior and lifestyle changes. Lifestyle modification programs could comprise a variety of topics such as stress management, exercise, diet, and medications (Carpenter, DiChiacchio, & Barker, 2019). Lifestyle modification programs have had a long history in managing diabetes because it usually combines interventions targeting behavior modification, exercise, diet, and medication management. Lifestyle modification programs such as self-efficacy, healthy diets, and greater exercise have helped patients with T2D manage their weight and control their glycemic and HbA1c levels (Delahanty et al., 2013; Kerrison et al., 2017; Carpenter, DiChiacchio, & Barker, 2019).

Problem-solving therapy (PST) is a strategy for behavioral modification used to determine what needs to be done to attain a goal that is not apparent (Carpenter, DiChiacchio, & Barker, 2019). Problem-solving therapy aims to minimize adverse emotional reactions, change behavior, and improve positive emotional responses (Zhang et al., 2018). Problem-solving therapy entails teaching individuals suffering from a chronic disease how to deal with life issues by breaking them down into two different sections: utilizing problem-solving skills and employing problem-solving orientations to life. Making their health a priority which requires being consistent with appointments regarding health care. Additionally, problem-solving therapy mainly focuses on teaching a patient skill such as recognizing the health issues, when to seek medical attention, defining the problems, comprehending them, setting health objectives associated with the health issue, identifying alternative strategies to solve the health issue, analyzing and selecting the best methods, implementing these alternatives, and analyzing their effort in solving the problem (Nezu et al., 2012).

Problem-solving therapy (PST) has had an extended history in counseling and clinical mindset to deal with substance abuse, coping skills and stress management, relational and family distress, and several mental health disorders. Additionally, problem-solving therapy has been constantly used within diabetes care and education and is recognized as a crucial skill, intervention, and process in diabetes self-management (Carpenter, DiChiacchio, & Barker, 2019).

Barriers to T2D self-management include lack of support, shortage of resources, inadequate behavioral beliefs, and knowledge, and suffering from health issues (Shi et al., 2020). When patients lack support from their families (such as lack of emotional support, taking medications, and eating healthy) and professionals, it interferes with the efficacy of self-management interventions. Some health issues, such as insomnia, physical discomfort, and hyperglycemia, could also interfere with self-care (Shi et al., 2020). These issues reduce patient motivation to engage in self-management interventions. Moreover, the shortage of resources, such as omitting doctor follow up visits, limited access to patient education, lack of finances to buy healthy foods, limited blood glucose monitoring, and unavailability of hypoglycemic medications.

Lastly, inadequate behavioral beliefs, knowledge, and confusion about taking diabetes medications interfere with the efficacy of diabetes self-management (Kulhawy-Wibe et al., 2018). Shi et al. (2020) found that many diabetic patients did not understand how to use hypoglycemic agents. Many were confused about the medications' side effects, usage, and names, which prevented them from efficiently managing diabetes. Recognizing these barriers is essential in creating effective strategies, including promoting successful self-management, implementing patient-centered care, reinforcing social and medical support, and creating favorable environments. Also, understanding these barriers will help patients understand how they will deal with them and educate their families and peers on how they can help them manage the disease on their own.

The project aims to promote and implement effective self-management for T2D in impoverished communities. Self-management could be one of the best alternatives for managing T2D among communities with inadequate access to quality healthcare since fewer financial resources are required than pharmacological means (Whittemore et al. 2019). For example, because T2D is mainly developed from poor diet and lifestyle practices, modifications such as eating a cleaner diet, exercising more often, and tracking glucose levels could help manage the disease. However, factors such as limiting beliefs among rural residents and lack of support from family could impede the effective use of self-management to control T2D (Shi et al. 2020). Therefore, this research will examine how such barriers could be addressed to ensure that patients manage T2D effectively without experiencing dire health effects. It will also look at how patient education could be improved within impoverished communities so that people with diabetes could learn how to manage the disease independently without the intervention of healthcare professionals.

This project utilizes the Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP). This model is structured to satisfy EBP needs by employing a simple process known as Practice Question, Evidence, and Translation (PET; Dang et. al. 2021). In the first step, the EBP question is created, followed by searching, appraising, describing, and rating the quality of evidence. In the last step, feasibility of the project is determined, an action plan for implementation is created, and evidence-based practice changes are implemented (Christenberry, 2017). Also, findings are presented to the larger nursing faculty and healthcare organizations.

Respondents have to meet the following eligibility criteria to participate in the study. The participants need to be clinically diagnosed with T2D, female or make above 18 years and be willing to participate in the study. The respondents that will be excluded from participating are either pregnant during the time of the project, had severe diabetes complications, renal dialysis, serious mental illness, or terminal or acute illness. The respondents that record HbA1C >7 will be invited to our organization for two months every Monday for diabetes support group meetings (the first month) and educational presentations (the second month). Signed written consents will be obtained before collecting Diabetes Self-Management (DSM) pre-surveys such as weight measurement and DSM practice and knowledge using questionnaires that will be answered with a Likert scale. Consenting participants will be assigned numbers, that is, P1, for Participant to maintain their confidentiality while participating in the project.

The weekly face-to-face diabetes support group meetings will comprise group exercises and discussions to follow up on their progress with DSM by examining their meal plans, glucose monitoring, medication issues, and insulin administration. This will be done using the teach-back method. Teach-back, also known as "Chunk and Check", "Ask, Tell Ask", or "Show Me”, is a highly effective, evidence-based communication technique used to enhance patient understanding when applied appropriately in a clinical setting (Tamura-Lis, 2013). Most patients often retain little to zero information in a clinical encounter; hence the teach-back method will help participants in this project solidify the practices and processes they should follow to attain better self-care.

Biweekly sessions for the first month, will also have different topics on managing T2D, including healthy life behaviors, dealing with negative emotions, insulin injection and medication administration, physical activity, nutrition, prevention of chronic diabetes complications, dealing with hypoglycemia and hyperglycemia, blood glucose self-monitoring, and other T2D basic knowledge. Other crucial practices introduced in these sessions include exercise logs and nutrition, plan-making, goal setting, problem-resolving skills, and brainstorming strategies. For the second month, educational presentations will be guided by the social support theory, self-determination theory, self-efficacy theory, and health belief model. The respondents will be called weekly (Fridays) for queries or follow-ups.

DSM Post-Surveys will be gathered monthly, including a DSM practice and knowledge using questionnaires that will be answered with a Likert scale. The data gathered from the first DSM Post-Survey (after the first month) and the second DSM Post-Survey (after the second month) will be compared to the data collected from DSM pre-surveys. The second DSM Post-Survey will include the respondents' latest weight, HbA1c, and glycemic levels.

The outcomes will be analyzed using different metrics. DSM pre-survey and the second DSM post-survey will include a five-item DSM questionnaire. This will be followed by a seven-item DSM questionnaire about self-management behaviors such as monitoring blood glucose, reducing complications or risks, problem-solving, healthy coping, taking medications, being active, and healthy eating (See Appendix E). The mean score will be compared to the data obtained in the DSM post-survey to determine if there is an improvement in self-care behaviors. The respondent’s weight, HbA1c, and glycemic levels will also be measured in the first week, before the educational sessions and at the end of the second month. These measurements will then be compared to establish whether there have been some improvements. During the DSM pre-survey, respondents will be assessed to determine if they have had a follow-up with their podiatrist, ophthalmologist, or endocrinologist in the last year.

During the first and the second visit, respondents’ knowledge of the main topic of discussion will be measured using a five-item post-test and pre-test (See Appendix F). To constantly examine the respondent’s knowledge on these topics, the project's participants will obtain a fourteen-item (two items for every behavior) post-test and pre-test for each T2D support group meeting. The teach-back method will be conducted in face-to-face meetings to assess the practice or competency of insulin administration and blood glucose monitoring.

The validity and reliability of data obtained from the project’s outcome metrics will be achieved using different strategies. First, the levels of the respondents will be measured to determine the health condition of a T2D patient before including them in the project. Respondents with HbA1c < 7% will be excluded from the project because they have effectively managed to use self-management practices. Only those with HbA1c > 7% will be included to enable a more valid assessment of their DSM and strategic ways to increase their education on self-care practices.

Semi-structured interviews will be used to gather evidence on the experiences of T2D patients. They will also be used to understand the experiences of family members in caring for family members with T2D. The interview questions will be developed by our organization’s multidisciplinary team, with expertise in health services, public health, and nursing. The main goal of these semi-structured interviews will be to assess the level of DSME among T2D patients and their families, to determine whether they have used self-management before, and to understand the adverse outcomes they have experienced while managing the disease using self-management interventions. The semi-structured interviews will be conducted at the community clinic and audio-recorded to help in later transcription.

A five-item DSM questionnaire will be administered to the respondents to obtain information on DSM practice and knowledge (See Appendix F). The questionnaires that will be used will be answered with a Likert scale. The questionnaires will also obtain the participant’s demographic information, including their gender, weight, and age.

Surveys will help gather important information on DSM among T2D patients and their families in this community. Three primary surveys will be conducted: the DSM pre-survey, the first DSM post-survey, and the second DSM post-surveys (See Appendix E). The primary purpose of the DSM pre-survey is to assess the respondents’ self-management practices. If a participant scores positive on the pre-survey, they will be advised to continue using self-management interventions and excluded from the project. This is because a positive score indicates that they fully understand self-management and have successfully used it to manage T2D. The participants who score poorly DSM pre-survey will be included in the project to be offered patient education and ensure they can handle the disease safely and efficiently on their own. The pre-survey will also allow DSM assessment using the respondent’s HbA1c over the past year. The respondents with HbA1c > 7% will be included in the project.

The primary purpose of the first DSM post-survey will be to obtain a patient’s weight, HbA1c, and glycemic levels. The mean score will be compared to the data obtained in the DSM pre-survey to determine if there is an improvement in self-care behaviours. This survey will be conducted after the first month. It will also be conducted to assess whether patients have adopted safe self-management practices. The second DSM post-survey will also be shown after the second month to determine if there have been improvements in a patient’s self-management behaviours. The respondents’ weight, HbA1c, and glycemic levels will also be obtained and compared to the first DSM post-survey measurements to assess any improvements.

The data obtained using the above data collection methods will be analysed differently. Averages and percentages will be used to determine the level of DSME that a patient has. The questionnaire will utilise a Likert scale through which the respondents will answer the structured questions. Totals will be obtained on the 5-item questionnaire and assessed to establish whether a patient has adequate knowledge of self-management.

Content analysis will also be used to obtain themes from the semi-structured interviews. To achieve methodological rigour, the discussions will be coded to resolve discrepancies in the information obtained from the interviews. Line coding will be used after the first ten interviews. These ten transcripts will then be re-coded through a code book to ensure they are complete. The emerging codes and sub-categories will then be organised into themes for further discussion and analysis.

Frequency counts will also be used to determine the number of times a particular characteristic occurs. For instance, a frequency cunt will be used to establish how many women and men have reported successfully using self-management practices. It will also determine how many respondents report frequent physical activity, recording and monitoring their blood sugar regularly, reducing complications and risks associated with T2D, healthy eating, coping, and taking medications.

References

Ahmad, A. (2021). Medication-taking behavior and treatment preferences of Indian migrants with type 2 diabetes in Australia (Doctoral dissertation).

American Diabetes Association (2022). About Us. https://diabetes.org/about-us

Aschbrenner, K. A., Naslund, J. A., Barre, L. K., Mueser, K. T., Kinney, A., & Bartels, S. J. (2015). Peer health coaching for overweight and obese individuals with serious mental illness: intervention development and initial feasibility study. Translational Behavioral Medicine, 5(3), 277-284.

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Figure 1: Driver Diagram

Table 2: SWOT Analysis

Appendix D- Institutional Review Board (IRB) Application Letter

Institutional Review Board (IRB) Application Letter

Title of the Project: Implementation of Type 2 Diabetes Self-Management Education in an Impoverished Community

Expected Number of Participants: 50 males and 50 females

Participant Age Group: 18-25

Purpose of the Project:

The project aims to endorse and implement practical self-management for T2D among patients in impoverished communities. The project hopes to shed light on some barriers to successfully implementing self-management within this population and devise strategies to help address them. This will be followed by an analysis of safe and effective ways to manage the disease without worsening a patient's health status. Once all the risks have been evaluated and addressed, patient education will be provided to patients and their families or friends to help successfully implement this alternative treatment intervention method.

Measures Taken to Protect Participants:

The project's purpose will be disclosed to participants to reduce the risks of adverse reactions and effects during the project. Respondents will recognize the importance of answering some interview questions with full disclosure. It will also help eliminate participants whose health status is poor to avoid further deteriorating their condition. The participants will also sign a consent letter to ensure that every person participates willingly. Pseudonyms will also be given to the participant instead of their actual names to maintain confidentiality.

Process of Selecting Respondents:

An advertisement will be posted at the community clinic to invite willing participants to engage in the project. Each participant will be interviewed before selection to conduct a cross-examination which will help determine the type of diabetes they have and whether they have other underlying conditions that could worsen with self-management practices. The selected sample will complete a disclosure consent form before the project starts.

Name of Project Manager

Date

*Use 5 level Likert Scale to answer the survey (1 being strongly disagreed and five being strongly agreed)

*Tick the correct answer

Sex:

Age:

Weight:

1. T2D is:

• weighing heavily

• too much blood glucose or sugar

• too much insulin

2. Blood sugar levels can be reduced through:

• Weight loss

• Carbohydrate-controlled diets

• Insulin injection

• All of the above

3. T2D:

• Can be managed through insulin, oral medication, more physical exercise, and healthy diets

• Has multiple causes and is strongly familial

• Is common

4. Hypoglycemia occurs while using oral medication and insulin therapy.

• True

• False

5. Blood sugar might increase when:

• Taking the wrong insulin therapy or the dose of drugs

• Eating junk and sugary items

• A person is losing weight